Clinical Correlation, Lecture 11 NEW

Types of thyroid malignancies:

Papillary carcinoma

Follicular carcinoma

Medullary carcinoma

Anaplastic carcinoma

Lymphoma

80-90% of thyroid maligcancies are:

Papillary thyroid carcinoma

What are the risk factors involved with papillary thyroid carcinoma?

1. Family history

2. Genetic mutations, elevating cancer development

3. Females are at a higher risk

These tumors are gray-tan, firm with irregular borders or circumscribed borders. The cut surfaces may have cystic components with associated calcifications, central papillary features.

Papillary thyroid carcinoma

The histology of this tumor is well-differentiated. It arises from abnormal FOLLICULAR CELLS of the thyroid. Tumor is composed of PAPILLARY STRUCTURES and complex branching. Eosinophic cytoplasm, nuclear pleomorphism. Psammoma bodies can also be seen.

Papillary thyroid carcinoma (histological features)

This type of thyroid malignancy accounts for 10-15% of all thyroid cancer cases. Derived from follicular cells with a well-circumscribed, fibrous capsule. It is well-differentiated and has a good prognosis if caught early.

Follicular carcinoma

This type of thyroid malignancy arises from the parafollicular (C-cells). It accounts for 1-2% of all thyroid cancers, with small round cells with finely granular cytoplasm. AMYLOID IS PRESENT, with possible calcifications. It can be low or high grade.

Medullary carcinoma

This type of thyroid malignancy makes up 1-2% of all cases. It is poorly or undifferentiated carcinoma. It is infiltrative WITHOUT a capsule. It has rapid growth with aggressive/metatastic potential. Necrosis can be seen, typically has poor prognosis.

Anaplastic carcinoma

the histology of thyroid malignancy can have pleomorphic, large cells with increased mitotic figures. Necrosis is seen with varying architecture (spindle cell, squamoid, giant cell).

Anaplastic carcinoma (histological features)

How are thyroid malignancies typically treated?

1. Complete or total thyroidectomy for all cancer cases

2. Radiation and chemotherapy

What are the steps in grossing a total thyroid?

1. Orient yourself

2. What is present

3. Weight and dimension

4. individual measurements of each lobe

5. Ink

6. Describe external surfaces

7. Serially section each component

8. Lesion, measure and describe

9. measurement to external capsule

10. Lymph nodes, if there is any (typically not, bilateral neck dissection come separate)

11. cassette summary

Normal parathyroid glands weigh about:

35-40 mg

Parathyroid glands produce:

PTH

PTH moderates what?

Calcium and phosphate metabolism, affecting bone, kidneys, and neuromuscular function

What are the most common neoplasms of the parathyroid?

Benign adenomas

These cells are the most abundant cells of the parathyroid. They synthesize, store, and secrete parathyroid hormone (PTH).

Chief cells

Chief cells morphology:

Uniform, polygonal cells with eosinophilic or clear cytoplasm

These cells of the parathyroid are less abundant of Chief cells. they arise from chief cells, but their purpose is not fully understood. Absent before puberty, increases in age.

Oxyphil cells

Oxyphil cell morphology:

Large with granular cytoplasm that stains intensely eosinophilic.

This type of tissue is also seen in the parathyroid. It infiltrates and accumulates in the parathyroid tissue with age.

Adipose tissue

This is the most common lesion of the parathyroid.

Parathyroid adenoma

Parathyroid adenomas can cause:

primary hyperparathyroidism

What is seen in primary hyperparathyroidism?

Increase in PTH

Increase in blood calcium levels, resulting in hypercalcinosis

abnormal deposition of calcium in the soft tissues

Kidney damage, such as urinary tract stones, excess calcium reduces the kidneys ability to filter the blood

How is primary hyperthyroidism typically treated?

Surgical resections

If a parathyroid is sent for frozen, it is usually used to:

1. confirm the presence of parathyroid gland

2. evaluate for parathyroid adenoma

A frozen section of parathyroid is also verified with intraoperative:

PTH blood levels

When a parathyroid adenoma is removed, the PTH level should:

drop back to normal, confirming the lesion was successfully removed

What are the 2 benign lesions of the parathyroid?

1. Adenomas (85%)

2. Hyperplasia (15%)

This type of benign parathyroid lesion is very common, usually is enlarged producing excess PTH. It is usually solitary lesions, may weigh from 300 mg to several grams. Also an increase in calcium.

Adenomas

This type of benign parathyroid lesion is 15% of parathyroid cases. All four glands will be enlarged, with an overproduction of PTH. There is an increase in calcium.

Hyperplasia

This is the malignancy that may occur in the parathyroid. It is rare and usually seen in older adults. It is a firm, lobulated mass with fibrous septae. It is typically large, >2.0 cm. It is associated with gene mutations, such as the CDC73 germline mutaiton.

Carcinoma

What is the grossing procedure of the parathyroid gland?

1. Evaluate via frozen

2. WEIGH

3. Describe the tissue (small red-pink, rubbery soft tissue)

4. Submit the remainder of the parathyroid tissue (tissue that was not used for the FS)

There are no defined criteria for staging a parathyroid carcinoma because:

it is rare

What considerations need to be made when staging a parathyroid carcinoma?

1. Tumor size

2. Tumor grade (well, moderately, poorly diff)

3. Local invasion

4. Lymph node involvement

5. Distant metastasis

The right adrenal gland is what shape?

Pyramidal shape, molded by LIVER

The left adrenal gland is what shape?

Semilunar/cresent shape, compressed by the spleen and kidney

What are the two portions of the adrenal gland?

1. adrenal cortex

2. Adrenal medulla

This portion of the adrenal gland is thin, peripheral tissue of the adrenal parenchyma, bright yellow in color.

Adrenal cortex

This portion of the adrenal gland is the central parenchyma, red-gray in color.

Adrenal medulla

The adrenal cortex will produce steroid hormones (3):

Cortisol

Aldosterone

Androgens (sex hormones)

The adrenal medulla will produce neuroendocrine hormones:

Epinephrine (adrenaline)

Norepinephrine

What are the three layers of the adrenal cortex?

Zona glomerulosa

Zona fasiculata

Zona reticularis

The zona glomerulosa produces:

mineralcorticoids, impacting salt regulation and blood pressure

ALDOSTERONE

The zona fasciculata produces:

glucocorticoids, impacting glucose metabolism

CORTISOL

The zona reticularis produces:

Sex hormone precursors

DHEA-S, convert to sex hormones ESTROGEN AND TESTOSTERONE

The medulla of the adrenal gland produces:

Catecholamines (20% epi/80% norepi)

The medulla of the adrenal gland will receive direct stimulation via the NS to stimulate the release of hormones from the:

chromaffin cells

The catecholamines moderate the flight or fight responses, like:

1. Increase HR and BP

2. Bronchodilation

3. Increased metabolism

What are the 3 benign neoplasms that can occur in the adrenal glands?

1. Adrenal hyperplasia

2. Adrenal adenomas

3. Pheochromocytomas

Pheochromocytomas arise in this area of the adrenal glands:

medulla

These type of benign neoplasms of the adrenal glands arise in the CORTEX. They are typically solitary, commonly found incidentally on imaging (e.g Cushing’s syndrome, an increase in ACTH and increase in cortisol)

Adrenal adenomas

This type of benign neoplasm of the adrenal gland can occur in both the cortex and medulla. typical gene mutations are the MEN IIa and IIb.

Adrenal hyperplasia

What are the 2 types of malignant neoplasms that can occur in the adrenal glands?

1. Adrenal carcinoma

2. Neuroblastoma (childrens)

This type of malignant neoplasm of the adrenal gland is large and variegated with hemorrhage and necrosis. A capsule may be present but invaded by tumor.

Adrenal carcinoma

this type of malignant neoplasm of the adrenal gland is most commonly found in children 5 years and under. tumors are soft, hemorrhagic and cystic.

Neuroblastomas

What are the characteristics of non-functional cortical adenoma (adrenal gland)?

1. MOST COMMON TUMOR OF ADRENAL GLAND

2. BENIGN

3. tumor that does NOT produce excess hormone

4. USUALLY ASYMPTOMATIC

5. Commonly found on abdominal CT (incidentally)

What are the characteristics of functional adenoma (adrenal gland)?

1. BENIGN

2. PRODUCE EXCESS HORMONE, INVOLVING ONE OR MORE ADRENAL HORMONES

3. Overproduction/imbalance of hormone effects of the body chemistry (manifests as irregular physiological signs/symptoms)

This type of adenoma of the adrenal gland is found in the adult population, occurring in people >70 years old. More common in women. It is identified via specific signs/symptoms of hormone dysregulation. It may cause Cushings/Conns syndrome.

Functional adenoma

Cushing’s syndrome causes issue with this hormone:

Cortisol

Conn’s syndrome causes issues with this hormone:

Aldosterone

Grossing procedure of benign adenoma of the adrenal gland:

1. What is present

2. Orientation (typically not oriented)

3. Weight and measurements

4. Describe external surfaces

5. INK ONE COLOR, THE EXTERNAL SURFACES

6. SERIALLY SECTION PERPENDICULAR TO THE LONG AXIS, IN THE PLANE OF THE ADRENAL GLAND

7. Eval. of cut surfaces (possible lesion)

8. Measure any lesion, if present

9. Describe lesion, if present

10. Distance to the margin

11. Lymph nodes NOT USUALLY SUBMITTED

What is submitted for a benign adrenal adenoma?

1. 2-3 sections of the mass and adjacent normal

2. one section of normal

There are no staging criterion of an adrenal adenoma because:

it is considered a benign lesion